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Using a Video Game Intervention to Increase Hospitalists’ Advance Care Planning Conversations with Older Adults: a Stepped Wedge Randomized Clinical Trial

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Abstract

Background

Guidelines recommend Advance Care Planning (ACP) for seriously ill older adults to increase the patient-centeredness of end-of-life care. Few interventions target the inpatient setting.

Objective

To test the effect of a novel physician-directed intervention on ACP conversations in the inpatient setting.

Design

Stepped wedge cluster-randomized design with five 1-month steps (October 2020–February 2021), and 3-month extensions at each end.

Setting

A total of 35/125 hospitals staffed by a nationwide physician practice with an existing quality improvement initiative to increase ACP (enhanced usual care).

Participants

Physicians employed for ≥ 6 months at these hospitals; patients aged ≥ 65 years they treated between July 2020–May 2021.

Intervention

Greater than or equal to 2 h of exposure to a theory-based video game designed to increase autonomous motivation for ACP; enhanced usual care.

Main measure

ACP billing (data abstractors blinded to intervention status).

Results

A total of 163/319 (52%) invited, eligible hospitalists consented to participate, 161 (98%) responded, and 132 (81%) completed all tasks. Physicians’ mean age was 40 (SD 7); most were male (76%), Asian (52%), and reported playing the game for ≥ 2 h (81%). These physicians treated 44,235 eligible patients over the entire study period. Most patients (57%) were ≥ 75; 15% had COVID. ACP billing decreased between the pre- and post-intervention periods (26% v. 21%). After adjustment, the homogeneous effect of the game on ACP billing was non-significant (OR 0.96; 95% CI 0.88–1.06; p = 0.42). There was effect modification by step (p < 0.001), with the game associated with increased billing in steps 1–3 (OR 1.03 [step 1]; OR 1.15 [step 2]; OR 1.13 [step 3]) and decreased billing in steps 4–5 (OR 0.66 [step 4]; OR 0.95 [step 5]).

Conclusions

When added to enhanced usual care, a novel video game intervention had no clear effect on ACP billing, but variation across steps of the trial raised concerns about confounding from secular trends (i.e., COVID).

Trial Registration

Clinicaltrials.gov; NCT 04557930, 9/21/2020.

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Data Availability:

Access to the de-identified dataset will be made available upon written request to the senior author.

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Acknowledgements:

The authors would like to thank Dartmouth Presidential Scholar undergraduate research assistants Allison Zheng, Deborah Feifer, Olivia Brody-Bizar for their help recruiting and enrolling trial participants, Devang Agarwal for data abstraction, and Derek C. Angus, MD at the University of Pittsburgh for his advice on the design of the trial.

Funding

This work was supported by the National Institute of Aging (P01AG019783, Barnato PI) and the Patrick and Catherine Weldon Donaghue Medical Research Foundation (Barnato PI). Hopewell Hospitalist is an iteration of a game funded by the National Library of Medicine (DP2 LM012339 Mohan).

Author information

Authors and Affiliations

  1. Department of Critical Care Medicine, University of Pittsburgh, Room 638 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA

    Deepika Mohan MD MPH

  2. The Dartmouth Institute for Health Policy & Clinical Practice and Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA

    A. James O’Malley PhD

  3. Advanced Communications Research Group, National Institute of Standards and Technology, U.S. Department of Commerce, Boulder, CO, USA

    Julia Chelen PhD

  4. Department of Medicine and The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA

    Meredith MacMartin MD MS

  5. The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA

    Megan Murphy MS

  6. Sound Physicians, Tacoma, WA, USA

    Mark Rudolph MD

  7. Geisel School of Medicine at Dartmouth, Lebanon, NH, USA

    Jaclyn A. Engel BA

  8. The Dartmouth Institute for Health Policy & Clinical Practice and Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA

    Amber E. Barnato MD MPH MS

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  1. Deepika Mohan MD MPH
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  8. Amber E. Barnato MD MPH MS
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Contributions

Study concept and design or acquisition and analysis of data: DM, AJO, JC, MM, MM, MR, JAE, AEB.

Drafting of the manuscript: DM.

Critical revision of the manuscript for important intellectual content: AJO, JC, MM, MM, MR, JAE, AEB.

All authors read and approved the final manuscript.

Corresponding author

Correspondence to Deepika Mohan MD MPH.

Ethics declarations

Ethics Approval and Consent to Participate

The Dartmouth Committee for the Protection of Human Subjects has approved this study (STUDY00031980). Given our recruitment strategy (email letters soliciting participation), we obtained permission to waive written consent for participation. The study team obtained electronic consent and explained the study protocol to all physicians who agreed to participate in the trial.

Consent for Publication:

Not applicable.

Competing interests:

The authors have no financial conflicts to disclose.

Disclaimer

The funding agencies reviewed the study but played no role in its design, analysis, or interpretation.

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Mohan, D., O’Malley, A.J., Chelen, J. et al. Using a Video Game Intervention to Increase Hospitalists’ Advance Care Planning Conversations with Older Adults: a Stepped Wedge Randomized Clinical Trial. J GEN INTERN MED 38, 3224–3234 (2023). https://doi.org/10.1007/s11606-023-08297-y

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